Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Current interventions for posttraumatic stress disorder (PTSD) are efficacious, yet effectiveness may be limited by adverse effects and high withdrawal rates. Acupuncture is an emerging intervention with positive preliminary data for PTSD. Objective: To compare verum acupuncture with sham acupuncture (minimal needling) on clinical and physiological outcomes. Design, Setting, and Participants: This was a 2-arm, parallel-group, prospective blinded randomized clinical trial hypothesizing superiority of verum to sham acupuncture. The study was conducted at a single outpatient-based site, the Tibor Rubin VA Medical Center in Long Beach, California, with recruitment from April 2018 to May 2022, followed by a 15-week treatment period. Following exclusion for characteristics that are known PTSD treatment confounds, might affect biological assessment, indicate past nonadherence or treatment resistance, or indicate risk of harm, 93 treatment-seeking combat veterans with PTSD aged 18 to 55 years were allocated to group by adaptive randomization and 71 participants completed the intervention protocols. Interventions: Verum and sham were provided as 1-hour sessions, twice weekly, and participants were given 15 weeks to complete up to 24 sessions. Main Outcomes and Measures: The primary outcome was pretreatment to posttreatment change in PTSD symptom severity on the Clinician-Administered PTSD Scale-5 (CAPS-5). The secondary outcome was pretreatment to posttreatment change in fear-conditioned extinction, assessed by fear-potentiated startle response. Outcomes were assessed at pretreatment, midtreatment, and posttreatment. General linear models comparing within- and between-group were analyzed in both intention-to-treat (ITT) and treatment-completed models. Results: A total of 85 male and 8 female veterans (mean [SD] age, 39.2 [8.5] years) were randomized. There was a large treatment effect of verum (Cohen d, 1.17), a moderate effect of sham (d, 0.67), and a moderate between-group effect favoring verum (mean [SD] Δ, 7.1 [11.8]; t90 = 2.87, d, 0.63; P = .005) in the intention-to-treat analysis. The effect pattern was similar in the treatment-completed analysis: verum d, 1.53; sham d, 0.86; between-group mean (SD) Δ, 7.4 (11.7); t69 = 2.64; d, 0.63; P = .01). There was a significant pretreatment to posttreatment reduction of fear-potentiated startle during extinction (ie, better fear extinction) in the verum but not the sham group and a significant correlation (r = 0.31) between symptom reduction and fear extinction. Withdrawal rates were low. Conclusions and Relevance: The acupuncture intervention used in this study was clinically efficacious and favorably affected the psychobiology of PTSD in combat veterans. These data build on extant literature and suggest that clinical implementation of acupuncture for PTSD, along with further research about comparative efficacy, durability, and mechanisms of effects, is warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT02869646.

Improvement in Long-COVID Symptoms Using Acupuncture: A Case Study.

Background: The long-COVID syndrome (LCS), defined by residual symptoms from acute COVID-19 for <60 days, affects about one-third of all COVID survivors and is an emerging public health challenge. Empirical data about the range of symptoms or the utility of acupuncture alone for the LCS are very limited. Case: This observational case study of a 46-year-old male with LCS was conducted to preliminarily define the range of symptoms, a Traditional Chinese Medicine (TCM) diagnostic structure, and evaluate the potential utility of prescribed acupuncture for LCS. Results: The primary TCM diagnostic patterns from this patient's LCS presentation included Lung Qi and Yin Deficiency, Qi and Blood Stagnation, and Spleen Qi Deficiency with dampness. Acupuncture for this patient was associated with reduced symptoms and signs of LCS. Conclusion: A preliminary TCM diagnostic structure for LCS was defined. Acupuncture appears to have been helpful for a patient with LCS. Further research is needed to demonstrate the efficacy of acupuncture and/or other TCM modalities for LCS.

Conceptualizing a Traditional Chinese Medicine and Pathology of Arousal Diagnostic and Pathophysiological Framework for Postacute Sequelae of COVID-19.

Introduction: The postacute sequelae of COVID-19 (PASC) is a serious heterogeneous condition that affects a significant minority of those who endured COVID-19. PASC involves multiple body systems and an illness trajectory that has stages now being identified in medical research. Objective: Traditional Chinese Medicine (TCM) and acupuncture are well suited to conceptualize and treat PASC and other postviral conditions. No description of TCM theory and its relationship with modern medical theory about PASC and its illness trajectory currently exists. Conclusion: The authors provide an overview of the potential value of TCM for conceptualizing and treating PASC with a few examples and clarify directions for research.

Evaluation of a Veterans Health Administration Whole Health for Mental Health Course for Clinicians.

Objectives: Veterans experience mental health disorders at higher rates than their civilian counterparts and also experience multiple barriers to mental health services. The Veterans Health Administration (VA) has implemented a Whole Health approach to make health care more person-focused and oriented toward promotion of health-sustaining behavior. We conducted an evaluation to investigate the effects of a Whole Health for Mental Health (WHMH) course for clinicians that focuses on shifting the perspective to a system of care in which mental health is incorporated as a core part of whole-person care. Design: We collected surveys before the course, immediately after the course, and at a 2-month follow-up. Settings/Location: The course was implemented in non-clinical settings in two VA medical centers (one in the Northeast and one in the Mountain West). Subjects: Our sample consisted of VA staff who enrolled in WHMH and completed a pre- and post-survey (n = 100) and follow-up survey (n = 99). Intervention: The WHMH is a 2-day face-to-face course that covers multiple aspects of mental health through a Whole Health lens. The course includes evidence-based practices within each aspect of mental health. The course also emphasizes implementation of Whole Health in clinicians' lives, their practice, and the health care system. Outcome measures: Attitudes were measured at pre-, post-, and follow-up assessments. The WHMH behaviors were measured at pre- and follow-up assessments. Results: There were statistically significant, large changes toward improvement from pre-test to post-test for all attitudes examined. These changes remained significant at follow-up, and the magnitude of change remained at least medium to large. Statistically significant, medium magnitude or larger improvements were found at follow-up for four of the five WHMH behavior outcomes examined. Conclusions: Our results suggest that clinicians can increase their attitudes and use of Whole Health concepts and both conventional and complementary approaches related to mental health issues.

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

Acupuncture for combat post-traumatic stress disorder: trial development and methodological approach for a randomized controlled clinical trial.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a significant public health problem, affecting approximately 7% of the general population and 13-18% of the combat Veteran population. The first study using acupuncture for PTSD in a civilian population showed large pre- to post-treatment effects for an empirically developed verum protocol, which was equivalent to group cognitive behavior therapy and superior to a wait-list control. The primary objective of this study is to determine both clinical and biological effects of verum acupuncture for combat-related PTSD in treatment-seeking US Veterans. METHODS: This is a two-arm, parallel-group, prospective randomized placebo-controlled clinical trial. The experimental condition is verum acupuncture and the placebo control is sham (minimal) acupuncture in 1-h sessions, twice a week for 12 weeks. Ninety subjects will provide adequate power and will be allocated to group by an adaptive randomization procedure. The primary outcome is change in PTSD symptom severity from pre- to post-treatment. The secondary biological outcome is change from pre- to post-treatment in psychophysiological response, startle by electromyographic (EMG) eyeblink. Assessments will be conducted at pre-, mid-, post-, and 1-month post-treatment, blind to group allocation. Intent-to-treat analyses will be conducted. DISCUSSION: The study results will be definitive because both clinical and biological outcomes will be assessed and correlated. Issues such as the number needed for recruitment and improvement, use of sham acupuncture, choice of biological measure, and future research need will be discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02869646 . Registered on 17 August 2016.

Patients with lesions to the intraparietal cortex show greater proprioceptive realignment after prism adaptation: Evidence from open-loop pointing and manual straight ahead.

Reaching toward a target viewed through laterally refracting prisms results in adaptation of both visual and (limb) proprioceptive spatial representations. Common ways to measure adaptation after-effect are to ask a person to point straight ahead with their eyes closed ("manual straight ahead", MSA), or to a seen target using their unseen hand ("open-loop pointing", OLP). MSA measures changes in proprioception only, whereas OLP measures the combined visual and proprioceptive shift. The behavioural and neurological mechanisms of prism adaptation have come under scrutiny following reports of reduced hemispatial neglect in patients following this procedure. We present evidence suggesting that shifts in proprioceptive spatial representations induced by prism adaptation are larger following lesions to the intraparietal cortex - a brain region that integrates retinotopic visual signals with signals of eye position in the orbit and that is activated during prism adaptation. Six healthy participants and six patients with unilateral intraparietal cortex lesions underwent prism adaptation. After-effects were measured with OLP and MSA. After-effects of control participants were larger when measured with OLP than with MSA, consistent with previous research and with the additional contribution of visual shift to OLP after-effects. However, patients' OLP shifts were not significantly different to their MSA shifts. We conclude that, for the patients, correction of pointing errors during prism adaptation involved proportionally more changes to arm proprioception than for controls. Since lesions to intraparietal cortex led to enhanced realignment of arm proprioceptive representations, our results indirectly suggest that the intraparietal cortex could be key for visual realignment.

Distress and Resilience in Resettled Refugees of War: Implications for Screening.

There is little work published about predictors of specific trajectory types of distress in refugees of war during early resettlement in a host country. Data about distress (Refugee Health Screener-15 (RHS-15)) and possible predictors of distress were collected at the domestic medical examination (T1) within 90 days of arrival and the civil surgeon examination (T2) 11-16 months after T1 for refugee groups from three countries (COU). Descriptive, correlative, analyses of variance, and regression techniques were used to determine trajectory type and their predictors. A higher percentage (7.3%) were distressed at T2 than at T1. By group, the Bhutanese became more distressed, the Burmese became less distressed, and Iraqi's continued to have high distress. A regression model showed gender, loss, post-migration stress, and self-efficacy to be significant predictors of trajectory type (R2 = 0.46). When the T1 RHS-15 score was added to the model, observed variance increased (R2 = 0.53) and T1 RHS score accounted for the majority of variance (r = 0.64, p < 0.001), with post-migration stress accounting for markedly less (ß = 0.19, p = 0.03). Loss and self-efficacy became less significant. Loss was, however, a strong predictor of delayed and chronic distress trajectory type. These data suggest that screening for distress should occur at least twice during resettlement to detect those with initial distress and those with delayed distress. Screening should be coupled with identifying other social determinants of health and a comprehensive assessment to determine the need for intervention for secondary prevention (i.e., reducing delayed distress) and treatment (reducing chronic distress).

An analysis of fear inhibition and fear extinction in a sample of veterans with obstructive sleep apnea (OSA): Implications for co-morbidity with post-traumatic stress disorder (PTSD).

Obstructive sleep apnea (OSA) is a respiratory condition characterized by interrupted sleep due to repeated, temporary collapse of the soft tissue of the upper airway that can lead to a cascade of physiological and psychological adverse health outcomes. The most common therapeutic interventions for OSA patients include the application of continuous positive airway pressure (CPAP) which acts to keep the airway open and, as such, provides less interrupted and more restorative sleep. Improved sleep has been linked to more efficacious treatments for psychiatric conditions most notably those that include cognitive-behavioral elements, new learning, and memory consolidation. In the current study, we investigated the acquisition, inhibition, and extinction of conditioned fear in OSA patients, before and after CPAP therapy, using an established fear-potentiated startle paradigm. Patients with OSA displayed an intact ability to acquire, inhibit, and extinguish fear prior to CPAP treatment and this ability was significantly enhanced following CPAP usage. In addition, those patients with more severe OSA, as measured by apnea-hypopnea index (AHI), were more likely to show improved fear inhibition and extinction. Lastly, we observed impairments in discrimination between reinforced and nonreinforced conditioned stimuli, in the inhibition of fear, and in fear extinction in a subset of patients with OSA and co-morbid posttraumatic stress disorder (PTSD). These data suggest that evolving treatment algorithms for PTSD should address disrupted sleep problems prior to initiation of inhibition/extinction-based exposure therapies.

Prazosin for treatment of post-traumatic stress disorder: a systematic review and meta-analysis.

BACKGROUND: Prazosin has been an accepted treatment for patients with post-traumatic stress disorder (PTSD) who experience sleep disturbances, including nightmares. Results of a recent large randomized control trial did not find benefit of prazosin vs placebo in improving such outcomes. A meta-analysis that includes this most recent trial was conducted to examine the pooled effect of prazosin vs placebo on sleep disturbances and overall PTSD symptoms in patients with PTSD. METHODS: A systematic review of the published literature on trials comparing prazosin vs placebo for improvement of overall PTSD scores, nightmares, and sleep quality was conducted. Hedges' g standardized mean differences (SMD) between prazosin and placebo were calculated for each outcome across studies. RESULTS: Six randomized placebo-controlled studies representing 429 patients were included in the analysis, including two studies with a crossover design. Results showed prazosin significantly improved overall PTSD scores (SMD = -0.31; 95% confidence intervals [CI]: -0.62, -0.01), nightmares (SMD = -0.75; 95% CI: -1.24, -0.27), and sleep quality (SMD = -0.57; 95% CI: -1.02, -0.13). In the largest trial, prazosin showed a reduction in clinical outcome measures similar to past studies, but a relatively large placebo effect size, particularly for nightmares, contributed to no treatment differences. CONCLUSIONS: Despite the results of a recent, large randomized study, pooled effect estimates show that prazosin has a statistically significant benefit on PTSD symptoms and sleep disturbances. Limitations that should be considered include heterogeneity of study design and study populations as well as the small number of studies conducted and included in this meta-analysis.

Cortical volume abnormalities in posttraumatic stress disorder: an ENIGMA-psychiatric genomics consortium PTSD workgroup mega-analysis.

Studies of posttraumatic stress disorder (PTSD) report volume abnormalities in multiple regions of the cerebral cortex. However, findings for many regions, particularly regions outside commonly studied emotion-related prefrontal, insular, and limbic regions, are inconsistent and tentative. Also, few studies address the possibility that PTSD abnormalities may be confounded by comorbid depression. A mega-analysis investigating all cortical regions in a large sample of PTSD and control subjects can potentially provide new insight into these issues. Given this perspective, our group aggregated regional volumes data of 68 cortical regions across both hemispheres from 1379 PTSD patients to 2192 controls without PTSD after data were processed by 32 international laboratories using ENIGMA standardized procedures. We examined whether regional cortical volumes were different in PTSD vs. controls, were associated with posttraumatic stress symptom (PTSS) severity, or were affected by comorbid depression. Volumes of left and right lateral orbitofrontal gyri (LOFG), left superior temporal gyrus, and right insular, lingual and superior parietal gyri were significantly smaller, on average, in PTSD patients than controls (standardized coefficients = -0.111 to -0.068, FDR corrected P values < 0.039) and were significantly negatively correlated with PTSS severity. After adjusting for depression symptoms, the PTSD findings in left and right LOFG remained significant. These findings indicate that cortical volumes in PTSD patients are smaller in prefrontal regulatory regions, as well as in broader emotion and sensory processing cortical regions.

Suicidal Ideation and Severity of Distress among Refugees Residing in Asylum Accommodations in Sweden.

Refugees worldwide suffer high levels of distress and are at increased risk for death by suicide. The Refugee Health Screener (RHS) was developed to screen for emotional distress among refugees and can be used to assess distress severity. This paper examines the association between distress severity and suicidal ideation in a sample of refugees residing in asylum accommodations. Data from the RHS and item 9 on the Patient Health Questionnaire-9 (PHQ-9) was analyzed. Results showed that individuals at moderate and severe levels of distress were much more likely to exhibit suicidal ideation than individuals with low levels of distress. Even though we cannot conclude that individuals with low levels of distress do not have thoughts of ending their lives, further suicide assessment is warranted in asylum seekers with moderate to severe distress on the RHS.

Mental Health Effects of Stress over the Life Span of Refugees.

Information about the relative impact of stressful events across the lifespan on the mental health of refugees is needed. Cross-sectional data from a community sample of 135 Kurdish and 117 Vietnamese refugees were fit to a path model about the effects of non-war stress, war-related stress, and post-migration stress on mental health. Kurdish and Vietnamese data were generally consistent with the model. However, war-related stress produced no direct but a large indirect effect through post-migration stress on mental health in Kurds. Vietnamese data indicated a modest direct war-related stress effect but no indirect influence through post-migration stress. Different types of stressful events lead to adverse mental health of displaced refugees in a somewhat group-dependent manner. Implications for prevention and treatment are discussed.

A Double-Blind, Placebo-Controlled Randomized Trial of Vilazodone in the Treatment of Posttraumatic Stress Disorder and Comorbid Depression.

OBJECTIVE: To determine the efficacy, safety, and tolerability of vilazodone in the treatment of posttraumatic stress disorder (PTSD) with comorbid mild-to-moderate depression. METHODS: A 12-week randomized, double-blind, placebo-controlled trial was conducted in adult outpatients who met DSM-IV criteria for PTSD with comorbid depression between February 2013 and September 2015. Participants were randomly assigned to receive vilazodone 40 mg/d or placebo, and outcome measures were obtained at scheduled visits. Primary outcome measures included change in PTSD symptoms from baseline to end of study as indexed by the Clinician-Administered PTSD Scale (CAPS) and PTSD Symptom Scale-Self-Report (PSS-SR). Secondary outcome measures of anxiety, depression, and impairment were obtained, as well as biomarker assessment at baseline and end of study. RESULTS: A total of 59 patients were randomly assigned to receive vilazodone (n = 29) or placebo (n = 30). Of those who were randomized, there were 25 completers in the vilazodone group and 22 completers in the placebo group. No significant differences were observed between the groups on any of the primary or secondary outcome measures. Vilazodone was generally well tolerated with few differences in the rate of adverse events between groups. CONCLUSIONS: Treatment with vilazodone 40 mg/d did not improve symptoms of PTSD and comorbid depression. Further investigation of the biological mechanisms underlying PTSD may lead to identification of improved therapeutic targets. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01715519.

Sleep-Disordered Breathing Impact on Efficacy of Prolonged Exposure Therapy for Posttraumatic Stress Disorder.

There is growing evidence that sleep disturbances may impede the utility of existing therapeutic interventions for people with posttraumatic stress disorder (PTSD). This retrospective medical record review examined the hypothesis that sleep disturbance affects the outcome of prolonged exposure (PE) therapy for PTSD. We identified 18 combat veterans with PTSD who had completed PE therapy. There were 6 subjects who had sleep-disordered breathing, 5 of whom were documented by sleep polysomnography. All subjects in the sleep-disordered group took part in a minimum of 10 sessions; the mean number of sessions was comparable between the sleep-disordered group and the group without a sleep disorder. Posttreatment PTSD Checklist scores were significantly reduced in those without a sleep disorder (-28.25; 58.0% reduction, F(1, 11) = 59.04, p < .001), but were not reduced in those with sleep-disordered breathing (-7.17; 13.5% reduction, dIGPP = 2.25 [independent groups pretest-posttest design]). These observations supported the hypothesis that the efficacy of PE therapy is affected by sleep quality. If these findings are replicated, treatment algorithms may need to incorporate the presence or absence of sleep disorders as a factor in treatment choice.

The Benefit of Conserving and Gaining Resources after Trauma: A Systematic Review.

BACKGROUND: Traumatic events involve loss of resources, which has consistently been found to be associated with developing stress-related illness such as posttraumatic stress disorder (PTSD). OBJECTIVE: The purpose of this systematic literature review was to determine if there is evidence for the salutatory effect of resource gain on PTSD, and if there are intervention models that utilize and assess gain in PTSD. DATA SOURCES: All relevant online databases were systematically searched using key terms and a method, detailed in Figure 1. RESULTS: Of 22 relevant articles, there were three intervention studies, one longitudinal naturalistic study, eleven non-intervention association studies focusing on PTSD, and eight non-intervention association studies not focusing on PTSD. The intervention and naturalistic studies showed a significant positive effect on PTSD by specifically targeting the gain of resources during an intervention. Other non-intervention research supports the notion that resource loss is pathogenic and resource gain is beneficial after traumatic exposure. CONCLUSIONS: Interventions that develop and assess effects of gain of various types of resources on stress-related illness should be encouraged. Interventions that already have proven efficacy for PTSD might include standardized assessment of resource loss and gain to further understand mechanisms of action.

Effective Screening for Emotional Distress in Refugees: The Refugee Health Screener.

Screening for emotional distress is important, but not widely available. This study assesses the utility of the Refugee Health Screener 15 (RHS-15) in a public health setting. Refugee Health Screener 15 and diagnostic proxy (DP) instruments assessing anxiety, depression, and posttraumatic stress disorder were administered to refugees from 3 countries at their public health examination. Properties of the RHS-15 and its components were evaluated utilizing appropriate methods. Scale Cronbach α was 0.95, and a factor analysis identified 1 factor accounting for 66% of scale variance. Refugee Health Screener 15 scores and cases discriminated between refugee groups similar to DPs. Refugee Health Screener 15 case sensitivity and specificity to DPs were acceptable (≥0.87/0.77). A shorter, 13-item component had acceptable metric properties. The RHS-15 appears to be a valid screener for emotional distress of refugees. The 13-item scale may be more efficient and as efficacious for case identification. The critical public health need and recommendations for implementation are discussed.

Mental health screening among newly arrived refugees seeking routine obstetric and gynecologic care.

Posttraumatic stress disorder (PTSD), anxiety, and depression are common mental health disorders in the refugee population. High rates of violence, trauma, and PTSD among refugee women remain unaddressed. The process of implementing a mental health screening tool among multiethnic, newly arrived refugee women receiving routine obstetric and gynecologic care in a dedicated refugee women's health clinic is described. The Refugee Health Screener-15 (RHS-15) is a culturally responsive, efficient, validated screening instrument that detects symptoms of emotional distress across diverse refugee populations and languages. An interdisciplinary community partnership was established with a local behavioral health services agency to facilitate the referral of women scoring positive on the RHS-15. Staff and provider training sessions, as well as the incorporation of bicultural, multilingual cultural health navigators, greatly facilitated linguistically appropriate care coordination for refugee women in a culturally sensitive manner. Twenty-six (23.2%) of the 112 women who completed the RHS-15 scored positive, of which 14 (53.8%) were Iraqi, 1 (3.8%) was Burmese, and 3 (11.5%) were Somali. Among these 26 women, 8 (30.8%) are actively receiving mental health services and 5 (19.2%) have appointments scheduled. However, 13 (50%) are not enrolled in mental health care because of either declining services (46.2%) or a lack of insurance (53.8%). Screening for mental disorders among refugee women will promote greater awareness and identify those individuals who would benefit from further mental health evaluation and treatment. Sustainable interdisciplinary models of care are necessary to promote health education, dispel myths, and reduce the stigma of mental health.

Gene expression analysis in combat veterans with and without post­traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is a common, debilitating and complex disorder. Numerous genetic and environmental factors are important in the genesis and maintenance of PTSD. Thus, gene expression analysis (GEA) is a critical technology for PTSD research since it detects essential genetic output affected by gene-environment interactions. Quality control methods are rarely reported in gene expression studies. The present study aimed to identify reliably expressed genes in whole blood samples from subjects with combat-induced PTSD (n=6) and, secondly, to investigate the expression of genes that may be differentially expressed in PTSD compared with an appropriate control group (n=11). Strict quality control methods were used. From a theoretically driven set of 42 genes, 17 were reliably detected using quantitative PCR on samples from 17 combat-exposed veterans. Four of these 17 genes were consistently and modestly correlated with clinical phenotypes and had significant expression effects on phenotypes. These genes regulate inflammatory systems and are regulated by the adrenergic system, consistent with peripheral markers important in PTSD. Inflammatory disinhibition may be involved in combat-induced PTSD, and may be responsible for the increased prevalence of inflammatory­related illnesses observed in PTSD. This is a preliminary study with a small sample size. A number of genes are not reliably detected by the current methodology. Improved detection methods are important to extend the current study and to further understand mechanisms in PTSD.